[Vascular ultrasonography]. / Gefäßsonographie.

Vascular ultrasound plays an important role in the visual depiction of arteries, veins, and changes of tissue in lymphatic diseases. In the case of arteries, this ranges from endothelial dysfunction over measuring the increase of intima media thickness to the detection of stenoses, occlusion, or aneurysm. Ultrasound helps to differentiate in functional arterial diseases such as primary and secondary Raynaud's syndrome as well as arterial compression syndromes like entrapment syndrome of different arterial regions or the chronic exceptional compartment syndrome of the lower leg. Ultrasound plays a central role in the diagnosis of rare arterial diseases like large vessel vasculitis, arterial dissection, cystic adventitial degeneration, and the differentiation of vascular malformation especially in children, thus, permitting ultrasound-guided intervention and follow-up controls. In venous thrombosis, sonography is the primary imaging method, while follow-up controls help in the prediction of recurrent venous thrombosis. Ultrasound is a tool to determine the cause and severity of chronic venous insufficiency and allows different therapeutic procedures for the treatment of varicose veins to be visually monitored.

[Revision of DEGUM ultrasound criteria for grading internal carotid artery stenoses and transfer to NASCET measurement]. / Ultraschallkriterien zur Graduierung von Stenosen der A. carotis interna - Revision der DEGUM-Kriterien und Transfer in NASCET-Stenosierungsgrade.

Since 1986, German ultrasound criteria for grading carotid stenosis have followed the local diameter reduction percentage consistent with the definition used in the European Carotid Surgery Trial (ECST) definition. To overcome the confusion caused by the coexisting grading method used in the North American Symptomatic Carotid Endarterectomy Trial (NASCET), a German interdisciplinary council on carotid artery stenosis has recommended the implementation of the NASCET grading system (distal diameter reduction percentage) as the standard. The multi-parametric German "DEGUM ultrasound criteria" consisting of combined Doppler and imaging criteria have consequently been revised and transferred to the NASCET definition. In addition, a novel differentiation between main (primary) and additional (secondary) criteria has been proposed. When these ultrasound criteria are combined, vascular sonography allows reliable grading of carotid disease.

[Chronic relapsing compartment syndrome]. / Das chronische rezidivierende Kompartmentsyndrom.

Chronic relapsing exertional compartment syndrome is not only found in young athletic subjects. Non-athletic patients can also suffer from exercise dependent pain in the lower limb. The syndrome is defined by increased tissue pressure in between a closed osteo-fibrous space resulting in disturbed microcirculation and finally irreversible neuroischemic damage. Pain increases during running and disappears gradually at rest. The diagnosis is based on the typical symptoms and so far on the pre-, 1 and 5 min post exercise intramuscular pressure measurement. We first describe sonographic criteria induced by increased compartment pressure, especially for the most frequent anterior compartment syndrome with compression of the deep veins, increased movement of arterial wall and finally enddiastolic closure of the anterior tibial artery. Duplex ultrasound also provides pathogenetic factors like popliteal and anterior entrapment, stenosis or hypoplasia of the anterior tibial artery or thrombosis of the deep muscle veins. Many patients are reporting a pain history over years, resulting in complete reduction of their sporting activity. The knowledge about pathogenesis, symptoms, diagnosis and therapy should help shorten the negative impact of the syndrome on their quality of life.

Changes of hemostasis, endogenous fibrinolysis, platelet activation and endothelins after percutaneous transluminal coronary angioplasty in patients with stable angina.

OBJECTIVES: This study investigated parameters of endogenous fibrinolysis, activation of coagulation and platelets, and endothelin levels before and after elective percutaneous transluminal coronary angioplasty (PTCA) in patients with stable coronary artery disease (CAD). BACKGROUND: Abrupt vessel closure is a serious short-term complication after PTCA and is often unforeseeable. Detailed insight into the effect of PTCA on hemostasis, platelets and the release of vasoconstrictive substances, which are among the mainly discussed mechanisms of abrupt vessel closure, is needed to enhance the safety of coronary intervention. METHODS: Plasma levels of markers of platelet activity, coagulation, endogenous fibrinolysis and endothelins were determined in 20 patients with stable CAD undergoing elective PTCA. The blood specimens were drawn before, immediately after, 1 h after intervention and on the next morning. RESULTS: All patients showed an initially uncomplicated PTCA. Regarding the efficacy of anticoagulation after receiving 15.000 IU heparin during PTCA, two groups were compared. In eight patients with ineffective anticoagulation production of thrombin and platelet activation directly after and 1 h after PTCA was significantly higher compared with 12 patients with effective anticoagulation. Despite the strong activation of coagulation, only a low fibrinolytic response could be observed. Endothelins rose significantly after PTCA in both groups but stayed longer on higher levels in patients with distinct thrombin generation. Three of the eight patients without sufficient heparin treatment suffered abrupt vessel closure. CONCLUSIONS: Initially uncomplicated dilation of coronary arteries leads to systemically measurable activation of coagulation and platelets in patients with ineffective doses of heparin and release of endothelins in all patients. Therefore, individual adjustment of anticoagulation and platelet inhibition in combination with effective antivasospastic substances are needed in every patient before, during and after initially uncomplicated PTCA to prevent this serious complication.

Activation of the fibrinolytic system in patients with coronary artery disease and hyperfibrinogenemia.

Elevated fibrinogen levels as well as an impaired activity of the fibrinolytic system are regarded as important cardiovascular risk factors. To elucidate a potential interrelation between fibrinogen as an indicator of a hypercoagulable state and the endogenous fibrinolytic function hemostatic and rheological as well as lipid parameters were determined in 224 consecutive patients, who underwent elective coronary angiography. In the selected study population of 81 men and 19 women with fibrinogen concentration either > or = 3.5 g/l (n = 70) or < or = 2.5 g/l (n = 30) hyperfibrinogenemia was found to be significantly associated with increased concentrations of plasmin-alpha 2-antiplasmin complex [PAP [median (25.-75. percentile)], 534 (361-680) micrograms/l vs. 289 (243-440) micrograms/l; p < 0.001] and tissue plasminogen activator (t-PA) antigen [9 (6-11) micrograms/l vs 8 (5-9) micrograms/l; p < 0.05] while this association was lost in the subgroup of patients with angiographically normal coronary arteries (n = 26). In addition to these findings fibrinogen was significantly correlated with PAP (r = 0.40, p < 0.001; n = 224) and t-PA antigen (r = 0.2, p < 0.01; n = 224) after adjustment for age, diabetes mellitus, lipid parameters and leucocyte counts. It can be argued that elevated fibrinogen levels in patients with coronary artery disease are concomitant with an activation of the fibrinolytic system.

Preoperative systemic etoposide/ifosfamide/doxorubicin chemotherapy combined with regional hyperthermia in high-risk sarcoma: a pilot study.

From November 1990 to September 1991, 23 adults with high-risk, nonmetastatic sarcomas (20 soft-tissue sarcomas and 3 chondrosarcomas) were entered in a pilot protocol (RHT-91) involving regional hyperthermia combined with systemic chemotherapy followed by surgery. Of these patients, 12 had undergone previous surgery and/or radiation, 5 had received previous multidrug chemotherapy, and 6 were previously untreated. A tumor size of > 8 cm and/or an extracompartmental tumor location (11 patients) or local recurrence (12 patients) were defined as high-risk factors in addition to tumor grading (21 patients had grade 2 or 3 sarcomas). Regional hyperthermia was produced by an electromagnetic deep-regional-heating device. For systemic chemotherapy, all patients received etoposide/ifosfamide/doxorubicin (EIA) and mesna, with regional hyperthermia being given only on days 1 and 4 in repeated EIA/regional hyperthermia cycles every 3 weeks. Tumor temperatures (range, 40 degrees-44 degrees C) were measured by invasive thermometry in all patients during each regional hyperthermia treatment. A total of 181 regional hyperthermia treatments were applied within the pelvic region (11 patients) or extremities (12 patients) bearing relatively large tumors (mean volume, 848 cm3). By the cutoff date for this analysis (October 15, 1991), 13 patients had undergone surgery after receiving 2-6 (mean, 3.8) cycles of EIA chemotherapy combined with regional hyperthermia; all tumors except one were resected without disfiguration. In 22 evaluable patients (minimum, 2 EIA plus regional hyperthermia cycles), the clinical response rate was 27%, with 6 patients showing partial responses (PRs). In addition, a pathologic response to preoperative thermochemotherapy was evaluable in 13 patients, with 4 responders (31%) having > 50% histologic necrosis. In all, 3 of the responders (1 PR and 2 patients with > 50% histologic necrosis) relapsed within 3 months of surgical resection. The other 7 responding patients (5 PRs and 2 patients with > 50% histologic necrosis) showed stable disease with local tumor control. The study (RHT-91) is continuing as a multicenter phase II trial (opened on November 19, 1991) in patients with high-risk soft-tissue sarcomas to test the potential of preoperative thermochemotherapy in regard to local control and survival.

[Cystic adventitial degeneration. An important differential diagnosis in intermittent claudication]. / Zystische Adventitiadegeneration. Eine wichtige Differentialdiagnose bei der Claudicatio intermittens.

The cystic adventitial degeneration is a rare disease, but an important differential diagnosis in patients with intermittent claudication. The amount of fluid in the cysts may vary and cause an intermittent compression of the artery. This explains the frequently intermittent symptomatology, leading to a critical ischemia if there is a complete obstruction of the artery. The histologic findings indicate that adventitial cysts are true ganglions. The intramural, uni- or multilocular cysts contain a gelatinous, muciform fluid. The diagnosis of a cystic adventitial degeneration should be considered in cases of isolated stenosis or occlusion of the popliteal artery. Realtime ultrasound helps to establish the diagnosis. The standard treatment has been surgical and has consisted a resectional and non-resectional technique. The ultrasound-directed percutaneous aspiration as a less invasive technique seems to be an effective treatment for this condition. The course, diagnostic and therapy of four patients is demonstrated.

Prospective study of 36 patients with 46 popliteal artery aneurysms with non-surgical treatment.

BACKGROUND: There is a lack of prospective studies with popliteal aneurysms (PAA) < 2 cm and the very few information about the natural cause of the disease. PATIENTS AND METHODS: Between 1995 and 2000 46 patients having 65 popliteal artery aneurysms have been examined. The mean diameter was 1.9 cm (0.8-4 cm). In 41% of the cases PAA were bilateral, additional extrapopliteal aneurysms were found in 37%. The PAA was occluded in 8 patients at the initial examination (mean diameter 2.4 cm: 1.4-4 cm). One of these patients had to be amputated (long-term diabetes, dialysis and severe generalized peripheral arteriosclerosis). Since no information could be obtained from two patients, it was possible to prospectively monitor 36 patients with 46 PAA (30 m, 6 f) over a period of 2.5 years. 19 patients were treated with platelet inhibitors, 16 with coumarin and one refused any thromboembolic prophylaxis. The patients were examined every year by telephone interview and duplexsonography. RESULTS: During the monitoring period there occurred two complete occlusions and one distal arterial progression, while 2 patients died, but no amputation. The total complication rate was 6.5% with a higher incidence in PAA > 2 cm of diameter (14.2 vs. 3.1%). All complications were found in PAA with mural thromboses. Coumarin seems to be superior platelet aggregation inhibitors with a complication rate of 0% vs. 14.3%. The mean increase in diameter during follow-up was dependent on PAA size, 1.5 mm/year for PAA > 2 cm vs. 0.7 mm/year for PAA < 2 cm. CONCLUSION: This prospective study emphasises the necessity of a prophylactical surgery in patients with an aneurysm diameter > 2 cm. In view of the low rate of complications of the natural course of PAA (6.5% of all PAA or 14.2% for PAA > 2 cm/2.5 years), the bypass surgery should be performed by an experienced vascular department. Patients with PAA < 2 cm or patients with contraindication for peripheral bypass should receive anticoagulation.

[Long-term results of unsuccessful thrombolysis and secondary thrombectomy of deep leg-pelvic vein thromboses: a critical analysis]. / Langzeitergebnisse nach erfolgloser Lyse und sekundärer Thrombektomie tiefer Bein-Beckenvenenthrombosen: eine kritische Analyse.

According to the literature, fibrinolytic therapy of acute thrombosis of the pelvic and deep lower leg fails in about 15%. As the primary patency rate correlates with the long term results, we intended to investigate whether the failures of 15% might be improved by a secondary thrombectomy. 87% of 31 thromboses treated by secondary thrombectomy were investigated by clinical, morphological and functional examinations. The data show that in case of the intervention taking place within 8 days (total age of the thrombus including the period of lysis treatment) the results were excellent, within 8-14 days they were still good. Patients below the age of 30 years benefited most by the therapy. However, the postulated "airtight effect" could not be demonstrated. Early diagnosis is of paramount importance. The period of lysis treatment should be limited and in case of failure a secondary thrombectomy should be offered to the patient.

Failure of reducing lower extremity amputations in diabetic patients: results of two subsequent population based surveys 1990 and 1995 in Germany.

BACKGROUND: A 50% reduction of lower extremity amputations during the subsequent 5 year period has been targeted by the St. Vincent-Declaration issued in 1989/90 for a better care of diabetic patients across Europe. PATIENTS AND METHODS: In two adjacent counties far off major city areas 10 hospitals without specialised diabetes centers in the area provide care to about 300,000 inhabitants. Based on the official operation books and verified by the individual patient file all patients amputated in the 10 hospitals during the years 1990 and 1995 were evaluated retrospectively. RESULTS: A total of 119 patients (66 males, 53 females, age median 72 years) were amputated in the 10 hospitals 1990, and 162 (89 males, 73 females, age median 74 years) in 1995. The proportion of diabetic amputees amounted to 70.6 and 62.3%, respectively. A trend towards more toe amputations in diabetic versus nondiabetic patients was seen in both surveys which reached significance in 1995 (59 vs. 41%; p < 0.05). Based on the total population and the estimated number of diabetic patients (5% of the population) 1.4 and 2/10,000 nondiabetics were amputated in 1990 and 1995, respectively, in contrast to 61 and 66/10,000 diabetic individuals, indicating a 44 fold and 33 fold excess risk of diabetic patients. CONCLUSION: It is concluded that these 2 surveys 5 years apart reveal a failure of reducing lower extremity amputations in people with diabetes--despite the objectives of the St. Vincent-Declaration.

[Thrombectomy after unsuccessful thrombolytic therapy of deep leg vein thromboses: an effective procedure?]. / Thrombektomie nach erfolgloser Lysetherapie tiefer Bein-Beckenvenenthrombosen: ein sinnvolles Verfahren?

Lysis of acute thromboses of the pelvic and deep lower leg veins is not always successful. According to the literature, 11-20% of the cases remain occluded. In such cases the majority of authors continue therapy with anticoagulants (heparin, dicumarol). 31 thromboses which had been unsuccessfully treated by lysis were subsequently thrombectomized after a few hours. All external iliac veins could be opened. The amount of occluded common iliac veins could be reduced from 94% to 16%. In 19% a stenosis due to a venous spur remained. The complete patency rate of the extremity veins could be improved by 55%. This shows that a marked improvement of the primary patency rate could be reached despite the failed lysis. This is a prerequisite of a favourable longtime result. An evaluation of the late results is planned and will be published at a later date.

[Value of color duplex ultrasound in diagnosis of insufficiency of perforant veins. A prospective study of 94 patients]. / Wertigkeit der Farb-Duplex-Sonographie in der Diagnose insuffizienter Vv. perforantes. Eine prospektive Untersuchung an 94 Patienten.

Using colour coded duplex sonography in pre-operative diagnosis of insufficient perforant veins we succeeded in accomplishing a close correspondence between diagnostic methods and intraoperative findings. We examined 94 patients suffering from primary varicosis by duplex sonography and found 334 perforant veins in total, i.e. 2.4 per leg, which we marked with special ink. Nearly 50% of the patients had also been examined by phlebography, which was evaluated by the vascular surgeons only. One third of the phlebographies were not satisfactory. The vascular surgeon evaluated the accuracy of perforant veins marked by duplex sonography with 95.8%, whereas the sufficient phlebographies only reached an accuracy of 65%. The insufficient phlebographies showed only 16% of the duplex-sonographically marked perforant veins. The confluence of the insufficient minor saphenous vein with the popliteal vein corresponded in all of the 22 cases with the sonographic findings. The colour coded duplex sonography enables the vascular surgeon to localize the insufficient perforant veins exactly and also provides for minimal tissue damage, which means a relevant decrease of postoperative pain.

[Incidence and symptomatology of lung embolism in relation to the site of deep venous thrombosis]. / Untersuchungen zur Häufigkeit und Symptomatologie der Lungenembolie in Abhängigkeit von der Lokalisation der tiefen Beinvenenthrombose.

The uncertainty about the true incidence of pulmonary embolism (PE) in connection with deep venous thrombosis (DVT) becomes evident when comparing the results of autopsy--vs. clinical studies, with the former showing a three-fold elevated rate of embolisation. In order to evaluate the percentage of clinically inapparent PE, all patients (65 females, 54 males, mean age 61.3 years) hospitalized between April 1989 and March 1990 with suspected DVT and/or PE underwent duplex-sonography and pulmonary scintigraphy. In 108 cases, DVT could be ascertained, whereas 11 patients only suffered from PE. In 57.4% of all DVT, PE was diagnosed. Of the 73 cases with PE, only 53.4% of the patient stated typical symptoms primarily. In more than 1/4 of the patients with primary symptoms of PE, no DVT could be diagnosed. There was no significant difference between the occurrence of PE in relation to the localisation of DVT, with 1/3 to 1/2 being asymptomatic. 1/4 of the patients with leg-thrombosis and 1/7 with thrombosis of the iliac vein did not complain of typical symptoms of thrombosis. Furthermore, an increased PE-rate seems to occur with an elevated ultrasound echogenity of the thrombus. As a result of the study pulmonary szintigrams seem to be indicated in all cases of DVT in order to evaluate the total PE risk.

[DRG-based cost analysis of inpatient conservative treatment of stage III/IV peripheral arterial occlusive disease]. / DRG-basierte Kostenanalyse zur stationären konservativen Behandlung der PAVK Stadium III/IV.

UNLABELLED: DRG-based cost analysis of inpatient conservative treatment of PAD stage III/IV BACKGROUND: In a prospective study carried out by the German Society of Angiology and the DRG Competence Center, Munich, the question was investigated whether the costs of conservative treatment of patients with PAOD stage III/IV (DRG F65) are adequately represented within the current G-DRG system. METHODS UND PATIENTS: Between September 1 and December 16, 2002, a total of 704 patients with DRG F65 (peripheral vascular diseases) were evaluated at 8 angiologic centers in Germany. Apart from the length of hospital stay, the total costs (cost equivalents) were calculated using a method developed by the DRG Research Group at the University of Münster. Moreover, the study population was compared with a German calculation sample for the DRGs F65A/B, as published by InEK. RESULTS: As it turned out, conservatively treated patients with PAOD stage III or IV (DRGs F65A/B) cause significantly (p < 0.001) higher costs and have significantly (p < 0.001) greater lengths of hospital stay than patients who were also assigned to DRG F65 because of other vascular diseases. At the same time it became clear that angiologic centers treat twice as many patients with critical limb ischemia in comparison with the German average. The reimbursement hitherto estimated by InEK covers not even half the cost actually produced by conservative treatment of PAD stage III/IV. CONCLUSION: To ensure a performance-related reimbursement, a new basis DRG for patients with PAD stage III/IV has to be created, as has ben proposed by the German Society of Angiology. Otherwise, adequate conservative therapy in accordance with existing guidelines, of patients who cannot be treated surgically or interventionally will not be possible any more in the future.

Improvement in the quality of life after i.v. PGE1 therapy for intermittent claudication.

BACKGROUND: Increasingly and justifiably, clinical studies are now being expected to investigate the influence of therapeutic measures also on the quality of life of the patient. PATIENTS AND METHODS: Since no data on the variability of changes in the quality of life of the patient following PGE1 treatment are so far available, the initial investigation was designed as an uncontrolled pilot study. 104 patients (median age 64.5 years) with a maximum of walking distance on the treadmill (3 km/12%) of 50-250 m were included and given a daily intravenous infusion of 60 micrograms PGE1 (Prostavasin) over a period of 4 weeks excluding weekends. This was followed by a treatment-free follow-up period of 3 months. Changes in the quality of life were recorded with both the newly developed disease-specific questionnaire PAVK-86, and the generic questionnaire SF 36; in addition, the pain-free and maximum walking distances on the treadmill were also established prior to and immediately following treatment, as also at the end of the follow-up period. RESULTS: The quality of life was significantly improved in all dimensions (functional status, complaints, pain, mood, anxiety, social life, treatment expectations) in addition to a marked increase in the median pain-free walking distance from 77 to 108 m (p < 0.001) and the maximum walking distance from 118 to 171 m (p < 0.001). At the end of the 3-month observation period, the improvement was essentially still demonstrable. CONCLUSION: The study has shown for the first time that treatment with intravenous PGE1 brings about not only the already known increase in the walking distance, but also a clinically relevant and significant improvement in the patient's quality of life.

[Risk profile and macroangiopathy in type II diabetics in medical practice]. / Risikoprofil und Makroangiopathie bei Typ-II Diabetikern in der ärztlichen Praxis.

The risk profile and the macro-vascular complications of patients with type II diabetes mellitus (NIDDM) was investigated in general practice patients for the first time in the FRG. It was the aim of the study to evaluate the efficacy of the therapy and possible improvements after detailed instructions in a random sample of well defined NIDDM in the greater Munich area. 290 NIDDM (187 female, 103 male) out of a total of 1500 patients treated by 22 general practitioners were randomly recruited for the study. First results indicated an excess morbidity of the NIDDM, e.g. 43.5% with HbA1c greater than 8%, hypertension in 73.8%, hypertriglyceridemia in 75%, hypercholesterolemia in 36.3% adipositas in 78%, and a micro/macro-albuminuria in 44.5%. A similar risk profile could be determined in cases with recently diagnosed NIDDM. The remarkable risk profile documents itself in the incidence of macro-vascular complications: 40.8% of the male and 43.2% of the female showed a peripheral arterial disease (pAVD), in 8% of all patients a carotid artery stenoses could be detected by means of doppler ultrasound technique; 46.6% of the male and 59.3% of the female patients showed symptoms of CHD. With the exception of the incidence of CHD in patients less than 64 years the duration of NIDDM had no influence on the macro-vascular complications as demonstrated in previous studies. The age however always had a significant influence on all three vascular regions examined. Albuminuria correlated as such with a number of risk factors showed a significant correlation with the incidence of pAVD and occurred more often in males with carotid artery stenoses. Other correlations established were: Hypercholesterolemia and FVIII ass. Ag respectively, and the incidence of carotid artery stenoses; blood pressure, F VIII ass. Ag and pAVD. In the female a negative correlation could be seen between the pAVD and the HDL-level. In patients with CHD sex specific correlations could be determined to blood pressure, HbA1c, c-peptide and triglyceride levels.

[Lung embolisms in a surgical patient sample. A retrospective study over 9 years]. / Lungenembolien im chirurgischen Krankengut. Eine retrospektive Studie über 9 Jahre.

In a retrospective study of surgical patients during a period of 9 years 296 cases of pulmonary embolism were recorded by analysing autopsy findings and perfusion pulmonary scans. The frequency of pulmonary embolism among patients who underwent a surgical procedure was 0.55%, the frequency of lethal pulmonary embolism was 0.15%. In autopsy disseminated micro-pulmonary embolism were often found (n = 129, 44%). With regard on the preceding operation a high frequency of pulmonary embolism after septic abdominal surgery (1.5%) and vascular surgery (0.9%) became obvious, especially after operations on the abdominal or thoracic aorta (2.1 resp. 4.8%). In 198 cases venous thrombosis were found. 104 (52%) of these were located in the cranial venous system and in 46 patients there was a connection to the site of central venous lines.